Quality in Healthcare

Starting our Journey Some PDCA training but little structure for solving & improvement Knew buzzwords but limited application knowledge (PDCA) Focus on regulatory compliance Physicians not engaged in improvement activities Quality metrics reported regulatory little process measurements No assessments on internal quality system failures Blame RCA s limited to adverse events early warning signs not recognized Little knowledge of 7 Quality Tools Control charts?? Organization had not adopted a formal approach to quality mgmt

Munroe Today Quality foundation established High Level Sponsorship VP level monitoring of projects Project Oversight Steering Committee Standardized approach to projects & implementation Created Project Management Resource Manual Educational Series for all team members Lunch & Learn, SSGB, Lean, Implementation JIT project management training Taking PDCA to next level Adopted systematic organization wide approach for continually improving all process which deliver quality services & products

Munroe Regional Medical Center recommends the use of Project Management as a formalized and structured method of managing change. Project Management focuses on achieving specifically defined outputs that are to be achieved by a certain time, to a defined quality and with a given level of resources so that planned outcomes are achieved. It requires welldefined methods and techniques for managing a team of people to accomplish a series of work tasks within a well-defined schedule and budget to bring about beneficial change or added value.

Adding Structure USE OF FORMS IN THE PROJECT PROCESS AT A GLANCE PROJECT START Opportunity for improvement identified **Project Charter Form ** Required forms Project Planning Checklist and Form Project Selection Worksheet MEETING FORMS **PAL Form **Team Roster **Stakeholder Analysis Worksheet SIPOC Worksheet Priority Matrix Project Test of Change Form **Minutes Form

Adding Structure PROJECT CONTINUATION Control Plan Form Project Evaluation Checklist 7 7 QUALITY TOOLS Histogram Scatter Diagram Cause & Effect Check Sheets Pareto Analysis Flow Chart Control Cart PROJECT CONCLUSION Project Closure Checklist Form **Communication & Education Celebrate

Initiate Project Defining the Tools Create Charter - Problem statement, scope, goal Select Sponsor, Project Manager, and Team Members PLAN Conduct Stakeholders Analysis Voice of the Customer Identify Resources, Barriers, Related Projects Understand current problem or process Set project timeline Gather baseline data Plan tests of change & associated activities Process flow of current state Deliverables Project Charter Stakeholder Analysis Set project timeline Gather baseline data Process flow DO Develop and implement improvement strategies Update Test of Change as required Deliverable Test of Change CHECK Analyze processes & data Quantify the problem(s) Determine causes of variation Identify process changes & solutions Design Change Management Plan Evaluate Results Revise process as needed to obtain defined goals. Check process outcomes against desired outcomes. Implement process changes & solutions Track impact of solutions using indicators and data collection methods Deliverable Graphical representation of data Updates to process flow ACT Develop & Distribute Communicate Plan Develop Education Plan Develop control plan for sustaining results Standardize the change Make necessary adjustments on data collected Identify lessons learned Debrief - Identify remaining issues, Potential Projects, Communicate successes Deliverables Process flow improvements Communication Plan Education Plan Control Plan Project Closure Checklist

Continuous Improvement RCA Sustainability Equip room audits Improvements to equipment Equipment Complicated Training ineffective 3 part system No Standard Waste identified Lifetime Opportunities 5S equip rooms

5S Initiatives BEFORE AFTER

UP Project An Example of Munroe s Quality Initiatives

Charter Problem Statement The current Universal Protocol process used in procedural areas has been increasingly ineffective as evident by the number of root causes performed since 2010. We have conducted 13 RCA s in 3 key areas: Radiology, OR and Transcription. There is a need to establish a robust process from the first step of information sharing to ensure correct patient, site and procedure are preformed each & every time. Even through the current process meets regulatory and/or accreditation requirements it has become evident that verifying critical error points and identification of critical to quality criteria has not been designed into our processes. This has resulted in a cumbersome process with extensive rework locating the appropriate documents needed by upstream processes. Also, the current process is void of visual cues and standardization.

Charter Deliverables GOAL: Design an effective Universal Protocol process to replace the current UP checklist process that is currently used. Process design should be inherent with lean methodologies to aid in creating a visual workplace. Process redesign to be completed with recommendation to sponsor(s) June 1 2014 In Scope 1. Procedural areas: OR, CVOR - transfer to other procedural areas after improvement (design). 2. Process Stakeholders 3. Dynamic Process Documents 4. Lean Improvement Strategies 5. Support functions 6. Project Mgmt Resource PDCA improvement structure 7. Surgeon office communication & relationship Out of Scope 1. All other areas that perform invasive procedures 2. Current regulatory requirements such as TJC or HIPPA. 3. Financial information and non clinical information received from patient. 4. Staffing patterns or process cycle times.

Identified Opportunities Booking Ticket One booking ticket for all service lines. One size does NOT fit all. Information obtained from surgeon office not consistent or missing vital information. Multiple calls to surgeon office to obtain information. Dynamic documents not identified as required early in process. Wrong information from the first step pushes wrong information downstream.

Booking Data Calls back July 2013 Case Bookings to Associated calls 50 45 40 35 30 25 20 15 10 5 0 1-Jul 2-Jul 3-Jul 5-Jul 8-Jul 9-Jul 10-Jul11-Jul12-Jul15-Jul16-Jul17-Jul18-Jul19-Jul22-Jul23-Jul24-Jul25-Jul26-Jul29-Jul30-Jul31-Jul Case Bookings 32 37 22 15 30 45 30 34 24 23 29 28 33 29 28 38 36 40 18 36 39 28 # of notes, changes or calls 24 36 17 11 26 43 28 27 26 24 26 28 26 28 23 37 33 33 14 30 31 27

Possible Solutions Surgical Booking Ticket SX Case #: OR Use Only PAT Case #: Design a booking ticket specific to service lines Patient Name: DOB: SSN# Home Phone: Work Phone: Payor: Surgery Date: Surgery Time: Surgeon: DX: Procedure: Est. Length of Surgery: Anesthesia Type: Supine Litho Lateral Prone Admission Date/Time: Admitting Physicians: Patient Type: ASC or IP PAT Date/Time: SEX: M or F Comments / Requests or Needs: Example of Ortho Draft Office Contact / Fax / Phone: Equipment: TKA THA TSA Smith&Nephew Other Fracture Table Fluoro Brain Lab McConnell Arm Holder Synthes Stryker Biomet Zimmer EBI Acumed Exactech Mini frag set Small frag set Large frag set Locking plate Specialty Plates (distal humerus / volar wrist / distal femur / proximal tibia) External Fixation (Agee Wrist Jack / Hoffman II : Large / Small / Mini / EBI) Canulated Screws (4.0 / 6.5 / 7.3) Cable system (Dall-miles / Zimmer) Humeral Nail Biomet Fibula Nail Gamma Nail IMHS (S&N) ACL Reconstruction Arthrex ACL set Autograft / Allograft ( ) Shoulder Instruments Arthrex Arthrotec Opus Anchors Cell saver Insurance:

Project Solutions Add Engineering Controls & Visual Cues Use CTQ requirements to determine needs of next process owners Build process with visuals Add & Verify visuals at case cart process Move visuals to patient & OR suite Establish universal colors for laterality: Example: Lime = left Rose = Right Establish UP checklist as source of information not just a check mark

Use Standard Visuals Rough Example Pre OP Patient given a card of universal color for laterality. Card will be signed by Surgeon and Patient. Patient will give card to OR. Case Cart Use of same color for laterality on cart. Remove visual and place on OR suite door while staging OR from case cart OR will validate laterality using visual and dynamic documents. OR will place card on visual of body in room.

Visual documents or devices: 1. Universal Protocol Site Identification Form L R - BiL 2. Communication Information Poster L R BiL 3. Colored Bouffant L - R 4. Time Out Sign 5. Time Out Beacon

Universal Protocol Site Identification Form Pre-Procedure Sign-in PAT /FLOOR Create Consent: Order matches patient verbalization Patient / Legal Representative actively confirms with RN Initial/date: / Verified Name / DOB with armband: Initial & Date / Patient states procedure & marks UP Site ID Form: Allergies & Reactions verified with Patient - see Surgical Checklist PAT/FLOOR Initial: SAU: POCU: Perioperative RN: Surgery verified with (dynamic documents): Initial as each are verified. SAU POCU Perioperative RN Armband: Armband: Armband: Schedule: Schedule: Schedule: Upon Entry to O.R. Room Perioperative RN has visualized site marking on patient and matches site marking on UP Site ID Form: Initial/date: / RN, Surgical Tech & Anesthesia Care Provider confirm identity, procedure, consent, & site marking upon entry to OR. Briefing: Concerns: Safety, allergies, or psychological. All members of the team have discussed care plan and have addressed concerns YES CRN Initial: Consent: Consent: Order: Order: Consent: Order: HHHH&P: H&P: H&P: Comments: Patient: Patient: Patient: POCU RN has visualized site marking on patient and matches site marking on UP Site ID Form: Initial/date: Blood Products: Blood Consent Form Complete YES NO Blood Refusal: YES NO If Yes, note Exceptions Blood Ordered: YES NO Specimen Drawn: Type/Screen or Type/Cross Initial/date: / Number of units available: Radiology images pertinent to procedure are available Yes No N/A Special equipment available Yes No N/A Implants available Yes No N/A Patient Label Medical Representative Present Yes No N/A

Time Out Script Check as Completed Universal Protocol Site Identification Form Perioperative RN STOP all movement, Anesthesia, Can you please identify our patient? Anesthesia States Patient s Name & Date of Birth Perioperative RN Read consent, verbatim Perioperative RN Ask CST what surgery are you set up for? CST States what procedure set up for & visualizes site marking. Perioperative RN Ask surgeon what surgery are you preforming? Surgeon States what surgery is being performed and site Perioperative RN Are there any concerns, (ie. Allergies, HCG, Medications on field) After completion of successful Time Out Tech removes Time Out Beacon Team members present for Time-Out: Perioperative RN: Scrub Person: Surgeon: Assistant: Anesthesia provider: Other: Discrepancies: Yes No Describe: Resolved? Yes No Explain: Comments: Completion of counts: Specimens identified & Labeled: Yes Yes Verify name of operative procedure: Yes Verify wound classification: Sign-Out Before the Surgeon leaves the O.R. Yes Patient Label Perioperative RN: Signature Date / Time

Universal Protocol Site Identification Form Surgical Site: Left (Have patient note site and initial) Initials PAT/FLOOR/Inpatient RN: SAU: POCU: Perioperative RN: Patient Label

UP Project

UP Project Outcomes 1. Booking ticket is user friendly and is sent completed from the surgeon s office. 2. Visual Aids are used in process by all stakeholders and match correct laterality as defined on Critical Documents Order & Consent. 3. Surgical checklist is used by stakeholders & patient. Comments Positive feedback from users (surgeon s office). Information on ticket is complete. Information on ticket is accurate. Number of calls per ticket tracked. Positive feedback from users re: visual aids. Equipment/supplies for case is available (no delays). Visual Aid used in OR room match all Critical Documents and room is set up per correct procedure. Items listed on surgical checklist are complete and accurate. Patient has indicated on checklist the correct site/side. Next Steps: Getting corporate approval to use!!